Download Principles of Adolescent Substance Use Disorder

Principles of Adolescent
Substance Use Disorder Treatment:
A Research-Based Guide
Principles of Adolescent
Substance Use Disorder Treatment:
A Research-Based Guide
This publication is in the public domain and may be used or reproduced in
its entirety without permission from NIDA. Citation of the source is appreciated.
NIDA wishes to thank the following individuals for their
helpful comments during the review of this publication:
Tina Burrell, M.A., Washington State Department of Social and Health Services
Connie Cahalan, Missouri Department of Mental Health
Barbara Cimaglio, Vermont Department of Health
Michael L. Dennis, Ph.D., Chestnut Health Systems
Rochelle Head-Dunham, M.D., Louisiana Department of Health and Hospitals
Scott W. Henggeler, Ph.D., Medical University of South Carolina
Sharon Levy, M.D., M.P.H., Children’s Hospital Boston
Kenneth J. Martz, Psy.D., CAS, Pennsylvania Department of Drug and Alcohol Programs
Kathy Paxton, M.S., West Virginia Bureau for Behavioral Health and Health Facilities
Paula D. Riggs, M.D., University of Colorado School of Medicine
Contents
FROM THE DIRECTOR.............................................................................................................................................1
I. INTRODUCTION ................................................................................................................................................2
II. PRINCIPLES OF ADOLESCENT SUBSTANCE USE DISORDER TREATMENT.............................................. 8
1. Adolescent substance use needs to be identified and addressed as soon as possible................................ 9
2. Adolescents can benefit from a drug abuse intervention even if they are not addicted to a drug................. 9
3. Routine annual medical visits are an opportunity to ask adolescents about drug use.................................. 9
4. Legal interventions and sanctions or family pressure may play an important role in getting
adolescents to enter, stay in, and complete treatment..................................................................................9
5. Substance use disorder treatment should be tailored to the unique needs of the adolescent...................... 9
6. Treatment should address the needs of the whole person, rather than just focusing on his
or her drug use............................................................................................................................................10
7. Behavioral therapies are effective in addressing adolescent drug use....................................................... 10
8. Families and the community are important aspects of treatment................................................................ 10
9. Effectively treating substance use disorders in adolescents requires also identifying and
treating any other mental health conditions they may have........................................................................10
10. Sensitive issues such as violence and child abuse or risk of suicide should be identified
and addressed............................................................................................................................................. 11
11. It is important to monitor drug use during treatment.................................................................................... 11
12. Staying in treatment for an adequate period of time and continuity of care afterward are important.......... 11
13. Testing adolescents for sexually transmitted diseases like HIV, as well as hepatitis B and C,
is an important part of drug treatment......................................................................................................... 11
III. FREQUENTLY ASKED QUESTIONS ...............................................................................................................12
1.
Why do adolescents take drugs? ...............................................................................................................13
2. What drugs are most frequently used by adolescents? .............................................................................13
3. How do adolescents become addicted to drugs, and which factors increase risk?.................................... 14
4. Is it possible for teens to become addicted to marijuana?..........................................................................14
5. Is abuse of prescription medications as dangerous as other forms of illegal drug use?............................. 15
6. Are steroids addictive and can steroid abuse be treated?..........................................................................15
7. How do other mental health conditions relate to substance use in adolescents?....................................... 16
8. Does treatment of ADHD with stimulant medications like Ritalin® and Adderall® increase
risk of substance abuse later in life?...........................................................................................................16
9. What are signs of drug use in adolescents, and what role can parents play in getting treatment?............ 16
10. How can parents participate in their adolescent child’s treatment? ........................................................... 17
11. What role can medical professionals play in addressing substance abuse
(including abuse of prescription drugs) among adolescents?.....................................................................17
12. Is adolescent tobacco use treated similarly to other drug use?.................................................................. 18
13. Are there medications to treat adolescent substance abuse? ................................................................... 18
14. Do girls and boys have different treatment needs? ....................................................................................18
15. What are the unique treatment needs of adolescents from different racial/ethnic backgrounds?............... 19
16. What role can the juvenile justice system play in addressing adolescent drug abuse?.............................. 19
17. What role do 12-step groups or other recovery support services play in addiction
treatment for adolescents?..........................................................................................................................19
IV. TREATMENT SETTINGS..................................................................................................................................20
Outpatient/Intensive Outpatient.........................................................................................................................21
Partial Hospitalization........................................................................................................................................21
Residential/Inpatient Treatment.........................................................................................................................21
V. EVIDENCE-BASED APPROACHES TO TREATING ADOLESCENT SUBSTANCE
USE DISORDERS.............................................................................................................................................22
BEHAVIORAL APPROACHES...........................................................................................................................23
Adolescent Community Reinforcement Approach (A-CRA)..........................................................................23
Cognitive-Behavioral Therapy (CBT)............................................................................................................24
Contingency Management (CM)...................................................................................................................24
Motivational Enhancement Therapy (MET) .................................................................................................24
Twelve-Step Facilitation Therapy..................................................................................................................24
FAMILY-BASED APPROACHES........................................................................................................................25
Brief Strategic Family Therapy (BSFT).........................................................................................................25
Family Behavior Therapy (FBT)....................................................................................................................25
Functional Family Therapy (FFT)..................................................................................................................26
Multidimensional Family Therapy (MDFT)....................................................................................................26
Multisystemic Therapy (MST).......................................................................................................................26
ADDICTION MEDICATIONS.............................................................................................................................26
Opioid Use Disorders....................................................................................................................................27
Alcohol Use Disorders..................................................................................................................................27
Nicotine Use Disorders.................................................................................................................................28
RECOVERY SUPPORT SERVICES..................................................................................................................28
Assertive Continuing Care (ACC).................................................................................................................28
Mutual Help Groups......................................................................................................................................29
Peer Recovery Support Services..................................................................................................................29
Recovery High Schools.................................................................................................................................29
TREATMENT REFERRAL RESOURCES................................................................................................................31
REFERENCES.........................................................................................................................................................32
From the Director
Since its first edition in 1999, NIDA’s Principles of Drug Addiction Treatment
has been a widely used resource for health care providers, families, and others
needing information on addiction and treatment for people of all ages. But recent
research has greatly advanced our understanding of the particular treatment
needs of adolescents, which are often different from those of adults. I thus am
very pleased to present this new guide, Principles of Adolescent Substance Use
Disorder Treatment, focused exclusively on the unique realities of adolescent
substance use—which includes abuse of illicit and prescription drugs, alcohol,
and tobacco—and the special treatment needs for people aged 12 to 17.
The adolescent years are a key window for both substance use and the
development of substance use disorders. Brain systems governing emotion and
reward-seeking are fully developed by this time, but circuits governing judgment
and self-inhibition are still maturing, causing teenagers to act on impulse, seek new sensations, and be
easily swayed by their peers—all of which may draw them to take risks such as trying drugs of abuse.
What is more, because critical neural circuits are still actively forming, teens’ brains are particularly
susceptible to being modified by those substances in a lasting way—making the development of a
substance use disorder much more likely.
Addiction is not the only danger. Abusing drugs during adolescence can interfere with meeting crucial
social and developmental milestones and also compromise cognitive development. For example, heavy
marijuana use in the teen years may cause a loss of several IQ points that are not regained even if users
later quit in adulthood. Unfortunately, that drug’s popularity among teens is growing—possibly due in part
to legalization advocates touting marijuana as a “safe” drug. Nor do most young people appreciate the
grave safety risks posed by abuse of other substances like prescription opioids and stimulants or newly
popular synthetic cannabinoids (“Spice”)—and even scientists still do not know much about how abusing
these drugs may affect the developing brain.
These unknowns only add to the urgency of identifying and intervening in substance use as early as
possible. Unfortunately, this urgency is matched by the difficulty of reaching adolescents who need help.
Only 10 percent of adolescents who need treatment for a substance use disorder actually get treatment.
Most teens with drug problems don’t want or think they need help, and parents are frequently blind to
indications their teenage kids may be using drugs—or they may dismiss drug use as just a normal part of
growing up.
Historically the focus with adolescents has tended to be on steering young people clear of drugs
before problems arise. But the reality is that different interventions are needed for adolescents at
different places along the substance use spectrum, and some require treatment, not just prevention.
Fortunately, scientific research has now established the efficacy of a number of treatment approaches
that can address substance use during the teen years. This guide describes those approaches, as well
as presents a set of guiding principles and frequently asked questions about substance abuse and
treatment in this age group. I hope this guide will be of great use to parents, health care providers, and
treatment specialists as they strive to help adolescents with substance use problems get the help they
need.
Nora D. Volkow, M.D.
Director
National Institute on Drug Abuse
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 1
I. Introduction
2 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
P
eople are most likely to begin
abusing drugs*—including
tobacco, alcohol, and illegal
and prescription drugs—
during adolescence and young
adulthood.‡ By the time they are seniors,
almost 70 percent of high school students will
have tried alcohol, half will have taken an illegal
drug, nearly 40 percent will have smoked a
cigarette, and more than 20 percent will have
used a prescription drug for a nonmedical
purpose.1 There are many reasons adolescents
use these substances, including the desire
for new experiences, an attempt to deal with
problems or perform better in school, and simple
peer pressure. Adolescents are “biologically
wired” to seek new experiences and take
risks, as well as to carve out their own identity.
Trying drugs may fulfill all of these normal
developmental drives, but in an unhealthy
way that can have very serious long-term
consequences.
Many factors influence whether an adolescent
tries drugs, including the availability of drugs
within the neighborhood, community, and school
and whether the adolescent’s friends are using
them. The family environment is also important:
Violence, physical or emotional abuse, mental
illness, or drug use in the household increase
the likelihood an adolescent will use drugs.
Finally, an adolescent’s inherited genetic
vulnerability; personality traits like poor impulse
control or a high need for excitement; mental
The adolescent brain is often likened
to a car with a fully functioning gas
pedal (the reward system) but weak
brakes (the prefrontal cortex).
*
The brain continues to develop through early adulthood. Mature brain regions at each
developmental stage are indicated in blue. The prefrontal cortex (red circles), which governs
judgment and self-control, is the last part of the brain to mature.
Source: PNAS 101:8174–8179, 2004.
health conditions such as depression, anxiety,
or ADHD; and beliefs such as that drugs are
“cool” or harmless make it more likely that an
adolescent will use drugs.2
The teenage years are a critical window of
vulnerability to substance use disorders,
because the brain is still developing
and malleable (a property known as
neuroplasticity), and some brain areas are
less mature than others. The parts of the
brain that process feelings of reward and
pain—crucial drivers of drug use—are the first
to mature during childhood. What remains
incompletely developed during the teen years
are the prefrontal cortex and its connections
to other brain regions. The prefrontal cortex is
responsible for assessing situations, making
sound decisions, and controlling our emotions
and impulses; typically this circuitry is not
mature until a person is in his or her mid-20s
(see figure, above).
The adolescent brain is often likened to a car
with a fully functioning gas pedal (the reward
system) but weak brakes (the prefrontal
cortex). Teenagers are highly motivated to
pursue pleasurable rewards and avoid pain,
In this guide, the terms drugs and substances are used interchangeably to refer to tobacco, alcohol, illegal drugs, and prescription medications used
for nonmedical reasons.
‡ Specifying the period of adolescence is complicated because it may be defined by different variables, and policymakers and researchers may
disagree on the exact age boundaries. For purposes of this guide, adolescents are considered to be people between the ages of 12 and 17.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 3
but their judgment and decision-making
skills are still limited. This affects their ability
to weigh risks accurately and make sound
decisions, including decisions about using
drugs. For these reasons, adolescents are
a major target for prevention messages
promoting healthy, drug-free behavior and
giving young people encouragement and skills
to avoid the temptations of experimenting with
drugs.3
Most teens do not escalate from trying drugs
to developing an addiction or other substance
use disorder;* however, even experimenting
with drugs is a problem. Drug use can be
part of a pattern of risky behavior including
unsafe sex, driving while intoxicated, or other
hazardous, unsupervised activities. And in
cases when a teen does develop a pattern of
repeated use, it can pose serious social and
health risks, including:
• school failure
• problems with family and other relationships
• loss of interest in normal healthy activities
• impaired memory
• increased risk of contracting an infectious
disease (like HIV or hepatitis C) via risky
sexual behavior or sharing contaminated
injection equipment
• mental health problems—including
substance use disorders of varying severity
• the very real risk of overdose death
How drug use can progress to addiction.
Different drugs affect the brain differently, but
a common factor is that they all raise the level
of the chemical dopamine in brain circuits that
control reward and pleasure.
The brain is wired to encourage life-sustaining
and healthy activities through the release
of dopamine. Everyday rewards during
adolescence—such as hanging out with
friends, listening to music, playing sports,
*
Despite popular belief, willpower alone
is often insufficient to overcome an
addiction. Drug use has compromised
the very parts of the brain that make it
possible to “say no.”
and all the other highly motivating experiences for
teenagers—cause the release of this chemical in
moderate amounts. This reinforces behaviors that
contribute to learning, health, well-being, and the
strengthening of social bonds.
Drugs, unfortunately, are able to hijack this process.
The “high” produced by drugs represents a flooding
of the brain’s reward circuits with much more
dopamine than natural rewards generate. This
creates an especially strong drive to repeat the
experience. The immature brain, already struggling
with balancing impulse and self-control, is more
likely to take drugs again without adequately
considering the consequences.4 If the experience
is repeated, the brain reinforces the neural links
between pleasure and drug-taking, making the
association stronger and stronger. Soon, taking
the drug may assume an importance in the
adolescent’s life out of proportion to other rewards.
The development of addiction is like a vicious
cycle: Chronic drug use not only realigns a person’s
priorities but also may alter key brain areas
necessary for judgment and self-control, further
reducing the individual’s ability to control or stop
their drug use. This is why, despite popular belief,
willpower alone is often insufficient to overcome
an addiction. Drug use has compromised the very
parts of the brain that make it possible to “say no.”
Not all young people are equally at risk for
developing an addiction. Various factors including
inherited genetic predispositions and adverse
experiences in early life make trying drugs and
developing a substance use disorder more likely.
Exposure to stress (such as emotional or physical
abuse) in childhood primes the brain to be sensitive
For purposes of this guide, the term addiction refers to compulsive drug seeking and use that persists even in the face of devastating consequences;
it may be regarded as equivalent to a severe substance use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5, 2013). The spectrum of substance use disorders in the DSM-5 includes the criteria for the DSM-4 diagnostic categories of abuse and
dependence.
4 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
Adolescents Differ from Adults in Substances Most Abused
80
18 – 25
70
26+
66.5
60
57.2
65.5
50
46.3
33.1
30
42.6
38.7
40
42.9
0
Alcohol
Marijuana Prescription
Drugs
Cocaine
Heroin
4.6
3.3
6.7
8.7
9.9
11.1
11.7
12.4
3.0
18.3
8.6
10
12.6
20
17.1
Percent of those who received past-year treatment
12 – 17
Hallucinogens Inhalants
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013.
to stress and seek relief from it throughout
life; this greatly increases the likelihood of
subsequent drug abuse and of starting drug use
early.5 In fact, certain traits that put a person
at risk for drug use, such as being impulsive
or aggressive, manifest well before the first
episode of drug use and may be addressed
by prevention interventions during childhood.6
By the same token, a range of factors, such
as parenting that is nurturing or a healthy
school environment, may encourage healthy
development and thereby lessen the risk of later
drug use.
Drug use at an early age is an important
predictor of development of a substance use
disorder later. The majority of those who have
a substance use disorder started using before
age 18 and developed their disorder by age 20.7
The likelihood of developing a substance use
disorder is greatest for those who begin use in
their early teens. For example, 15.2 percent of
people who start drinking by age 14 eventually
develop alcohol abuse or dependence (as
compared to just 2.1 percent of those who wait
until they are 21 or older),8 and 25 percent of
those who begin abusing prescription drugs at
age 13 or younger develop a substance use
disorder at some time in their lives.9 Tobacco,
alcohol, and marijuana are the first addictive
substances most people try. Data collected
in 2012 found that nearly 13 percent of those
with a substance use disorder began using
marijuana by the time they were 14.10
When substance use disorders occur in
adolescence, they affect key developmental
and social transitions, and they can interfere
with normal brain maturation. These potentially
lifelong consequences make addressing
adolescent drug use an urgent matter. Chronic
marijuana use in adolescence, for example, has
been shown to lead to a loss of IQ that is not
recovered even if the individual quits using in
adulthood.11 Impaired memory or thinking ability
and other problems caused by drug use can
derail a young person’s social and educational
development and hold him or her back in life.
The serious health risks of drugs compound
the need to get an adolescent who is abusing
drugs into treatment as quickly as possible.
Also, adolescents who are abusing drugs are
likely to have other issues such as mental health
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 5
problems accompanying and possibly contributing
to their substance use, and these also need to
be addressed.12 Unfortunately, less than one
third of adolescents admitted to substance abuse
treatment who have other mental health issues
receive any care for their conditions.13
Adolescents’ drug use and treatment needs
differ from those of adults. Adolescents in
treatment report abusing different substances than
adult patients do. For example, many more people
aged 12–17 received treatment for marijuana
use than for alcohol use in 2011 (65.5 percent
versus 42.9 percent), whereas it was the reverse
for adults (see figure, page 5). When adolescents
do drink alcohol, they are more likely than adults
to binge drink (defined as five or more drinks in a
row on a single occasion).14 Adolescents are less
likely than adults to report withdrawal symptoms
when not using a drug, being unable to stop
using a drug, or continued use of a drug in spite
of physical or mental health problems; but they
are more likely than adults to report hiding their
substance use, getting complaints from others
about their substance use, and continuing to use
in spite of fights or legal trouble. substance use problems often feel they do
not need help, engaging young patients in
treatment often requires special skills and
patience.
Many treatment approaches are available to
address the unique needs of adolescents.
The focus of this guide is on evidence-based
treatment approaches―those that have been
scientifically tested and found to be effective
in the treatment of adolescent substance
abuse. Whether delivered in residential or
inpatient settings or offered on an outpatient
basis, effective treatments for adolescents
primarily consist of some form of behavioral
therapy. Addiction medications, while effective
and widely prescribed for adults, are not
generally approved by the U.S. Food and
Drug Administration (FDA) for adolescents.
However, preliminary evidence from controlled
trials suggest that some medications may
assist adolescents in achieving abstinence,
so providers may view their young patients’
needs on a case-by-case basis in developing a
personalized treatment plan.
Adolescents also may be less likely than adults
to feel they need help or to seek treatment on
their own. Given their shorter histories of using
drugs (as well as parental protection), adolescents
may have experienced relatively few adverse
consequences from their drug use; their incentive
to change or engage in treatment may correspond
to the number of such consequences they have
experienced.15 Also, adolescents may have more
difficulty than adults seeing their own behavior
patterns (including causes and consequences of
their actions) with enough detachment to tell they
need help.
Whatever a person’s age, treatment is not “one
size fits all.” It requires taking into account the
needs of the whole person—including his or
her developmental stage and cognitive abilities
and the influence of family, friends, and others
in the person’s life, as well as any additional
mental or physical health conditions. Such
issues should be addressed at the same time
as the substance use treatment. When treating
adolescents, clinicians must also be ready
and able to manage complications related to
their young patients’ confidentiality and their
dependence on family members who may or
may not be supportive of recovery.
Only 10 percent of 12- to 17-year-olds needing
substance abuse treatment actually receive any
services.16 When they do get treatment, it is often
for different reasons than adults. By far, the largest
proportion of adolescents who receive treatment
are referred by the juvenile justice system (see
figure, page 7). Given that adolescents with
Supporting Ongoing Recovery—Sustaining
Treatment Gains and Preventing Relapse
Enlisting and engaging the adolescent in
treatment is only part of a sometimes long and
complex recovery process.17 Indeed, treatment
is often seen as part of a continuum of care.
When an adolescent requires substance
6 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
Number of Adolescents Aged 12–17 Admitted to Publicly Funded
Substance Abuse Treatment Facilities on an Average Day, by Principal
Source of Referral: Treatment Episode Data Set 2008*
200
184
150
100
63
50
46
0
Juvenile
Justice
System
Self or
Others
43
Community
Organizations
Schools
28
Treatment
Providers
Source: 2008 SAMHSA Treatment Episode Data Set (TEDS)
abuse treatment, follow-up care and recovery
support (e.g., mutual-help groups like 12-step
programs) may be important for helping teens
stay off drugs and improving their quality of life.
When substance use disorders are identified
and treated in adolescence—especially if they
are mild or moderate—they frequently give
way to abstinence from drugs with no further
problems. Relapse is a possibility, however, as
it is with other chronic diseases like diabetes
or asthma. Relapse should not be seen as a
sign that treatment failed but as an occasion
to engage in additional or different treatment.
Averting and detecting relapse involves
*
18
Other
Health
Care
Professionals
monitoring by the adolescent, parents, and
teachers, as well as follow-up by treatment
providers. Although recovery support programs
are not a substitute for formal evidence-based
treatment, they may help some adolescents
maintain a positive and productive drug-free
lifestyle that promotes meaningful and beneficial
relationships and connections to family, peers,
and the community both during treatment and
after treatment ends. Whatever services or
programs are used, an adolescent’s path to
recovery will be strengthened by support from
family members, non-drug-using peers, the
school, and others in his or her life.
“Treatment providers” in this chart refers to “alcohol/drug abuse care providers.” Treatment providers can and do refer people to treatment if, for
example, a person is transferring from one level of treatment to another and the original facility does not provide the level of treatment that the person
needs, or if a person changes facilities for some other reason. “Other health care professionals” refers to physicians, psychiatrists, or other licensed
health care professionals or general hospitals, psychiatric hospitals, mental health programs, or nursing homes.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 7
II. Principles of Adolescent Substance Use Disorder Treatment
8 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
1. Adolescent substance use needs to
be identified and addressed as soon
as possible. Drugs can have long-lasting
effects on the developing brain and
may interfere with family, positive peer
relationships, and school performance.
Most adults who develop a substance use
disorder report having started drug use in
adolescence or young adulthood, so it is
important to identify and intervene in drug
use early.
2.Adolescents can benefit from a drug
abuse intervention even if they are
not addicted to a drug.18 Substance use
disorders range from problematic use to
addiction and can be treated successfully
at any stage, and at any age. For young
people, any drug use (even if it seems
like only “experimentation”), is cause for
concern, as it exposes them to dangers
from the drug and associated risky
behaviors and may lead to more drug use
in the future. Parents and other adults
should monitor young people and not
underestimate the significance of what may
appear as isolated instances of drug taking.
3. Routine annual medical visits are
an opportunity to ask adolescents
about drug use. Standardized screening
tools are available to help pediatricians,
dentists, emergency room doctors,
psychiatrists, and other clinicians determine
an adolescent’s level of involvement (if
any) in tobacco, alcohol, and illicit and
nonmedical prescription drug use.19 When
an adolescent reports substance use,
the health care provider can assess its
severity and either provide an onsite brief
intervention or refer the teen to a substance
abuse treatment program.20, 21
4.Legal interventions and sanctions or
family pressure may play an important
role in getting adolescents to enter, stay
in, and complete treatment. Adolescents
with substance use disorders rarely feel
they need treatment and almost never
seek it on their own. Research shows that
treatment can work even if it is mandated or
entered into unwillingly.22
5.Substance use disorder treatment
should be tailored to the unique
needs of the adolescent. Treatment
planning begins with a comprehensive
assessment to identify the person’s
strengths and weaknesses to be
addressed. Appropriate treatment considers
an adolescent’s level of psychological
development, gender, relations with family
and peers, how well he or she is doing in
school, the larger community, cultural and
ethnic factors, and any special physical or
behavioral issues.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 9
Components of Comprehensive
Drug Abuse Treatment
Vocational
Services
Family
Services
Assessment
Mental
Health
Services
Evidence-Based Treatment
Legal
Services
Substance Use Monitoring
Clinical and Case Management
Recovery Support Programs
Continuing Care
HIV/AIDS
Services
Medical
Services
Educational
Services
The best treatment programs provide a combination of therapies
and other services to meet the needs of the individual patient.
6.Treatment should address the needs
of the whole person, rather than
just focusing on his or her drug
use. The best approach to treatment
includes supporting the adolescent’s
larger life needs, such as those related
to medical, psychological, and social
well-being, as well as housing, school,
transportation, and legal services.
Failing to address such needs
simultaneously could sabotage the
adolescent’s treatment success.
Many adolescents who abuse drugs
have a history of physical, emotional,
and/or sexual abuse or other trauma.
7.Behavioral therapies are effective
in addressing adolescent drug use.
Behavioral therapies, delivered by trained
clinicians, help an adolescent stay off drugs
by strengthening his or her motivation to
change. This can be done by providing
incentives for abstinence, building skills
to resist and refuse substances and deal
with triggers or craving, replacing drug use
with constructive and rewarding activities,
improving problem-solving skills, and
facilitating better interpersonal relationships.
8.Families and the community are
important aspects of treatment. The
support of family members is important
for an adolescent’s recovery. Several
evidence-based interventions for adolescent
drug abuse seek to strengthen family
relationships by improving communication
and improving family members’ ability to
support abstinence from drugs. In addition,
members of the community (such as school
counselors, parents, peers, and mentors)
can encourage young people who need help
to get into treatment—and support them
along the way.
9.Effectively treating substance use
disorders in adolescents requires
also identifying and treating any other
mental health conditions they may have.
Adolescents who abuse drugs frequently
also suffer from other conditions including
depression, anxiety disorders, attentiondeficit hyperactivity disorder (ADHD),
oppositional defiant disorder, and conduct
problems.23 Adolescents who abuse drugs,
particularly those involved in the juvenile
justice system, should be screened for other
psychiatric disorders. Treatment for these
problems should be integrated with the
treatment for a substance use disorder.
10 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
10.Sensitive issues such as violence
and child abuse or risk of
suicide should be identified and
addressed. Many adolescents who
abuse drugs have a history of physical,
emotional, and/or sexual abuse or
other trauma.24 If abuse is suspected,
referrals should be made to social
and protective services, following local
regulations and reporting requirements.
11.It is important to monitor drug use
during treatment. Adolescents recovering
from substance use disorders may
experience relapse, or a return to drug
use. Triggers associated with relapse
vary and can include mental stress and
social situations linked with prior drug
use. It is important to identify a return
to drug use early before an undetected
relapse progresses to more serious
consequences. A relapse signals the need
for more treatment or a need to adjust the
individual’s current treatment plan to better
meet his or her needs.
12.Staying in treatment for an adequate
period of time and continuity of care
afterward are important. The minimal
length of drug treatment depends on
the type and extent of the adolescent’s
problems, but studies show outcomes are
better when a person stays in treatment for
3 months or more.25 Because relapses often
occur, more than one episode of treatment
may be necessary. Many adolescents
also benefit from continuing care following
treatment,26 including drug use monitoring,
follow-up visits at home,27 and linking the
family to other needed services.
A relapse signals the need for more
treatment or a need to adjust the
individual’s current treatment plan.
13.Testing adolescents for sexually
transmitted diseases like HIV, as well
as hepatitis B and C, is an important
part of drug treatment. Adolescents
who use drugs—whether injecting or
non-injecting—are at an increased risk
for diseases that are transmitted sexually
as well as through the blood, including
HIV and hepatitis B and C. All drugs
of abuse alter judgment and decision
making, increasing the likelihood that an
adolescent will engage in unprotected
sex and other high-risk behaviors
including sharing contaminated drug
injection equipment and unsafe tattooing
and body piercing practices––potential
routes of virus transmission. Substance
use treatment can reduce this risk both
by reducing adolescents’ drug use (and
thus keeping them out of situations in
which they are not thinking clearly) and
by providing risk-reduction counseling to
help them modify or change their highrisk behaviors.28,29
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 11
III. FREQUENTLY ASKED QUESTIONS
12 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
■ Illegal Drugs
■ Prescription or OTC Drugs
30
Tranquilizers
Hallucinogens
MDMA (Ecstasy)
4.6
4.5
4.0
Salvia
Sedatives
4.8
3.4
Cough Medicine
5
Prescription Painkillers*
10
7.1
15
Synthetic Marijuana
20
5.0
25
7.9
Alcohol and tobacco are the drugs most
commonly abused by adolescents, followed by
marijuana. The next most popular substances
differ between age groups. Young adolescents
tend to favor inhalant substances (such as
breathing the fumes of household cleaners,
35
Amphetamines A
What drugs are most
frequently used by
adolescents?
40
8.7
2.
Most Commonly Abused Drugs by
High School Seniors (Other than
Tobacco and Alcohol)
Marijuana
Adolescents experiment with drugs or continue
taking them for several reasons, including:
• To fit in: Many teens use drugs “because
others are doing it”—or they think others
are doing it—and they fear not being
accepted in a social circle that includes
drug-using peers.
• To feel good: Abused drugs interact with
the neurochemistry of the brain to produce
feelings of pleasure. The intensity of this
euphoria differs by the type of drug and how
it is used.
• To feel better: Some adolescents suffer
from depression, social anxiety, stressrelated disorders, and physical pain. Using
drugs may be an attempt to lessen these
feelings of distress. Stress especially plays
a significant role in starting and continuing
drug use as well as returning to drug use
(relapsing) for those recovering from an
addiction.
• To do better: Ours is a very competitive
society, in which the pressure to perform
athletically and academically can be
intense. Some adolescents may turn to
certain drugs like illegal or prescription
stimulants because they think those
substances will enhance or improve their
performance.
• To experiment: Adolescents are often
motivated to seek new experiences,
particularly those they perceive as thrilling
or daring.
glues, or pens; see “The Dangers of Inhalants,”
page 15), whereas older teens are more likely
to use synthetic marijuana (“K2” or “Spice”) and
prescription medications—particularly opioid
pain relievers like Vicodin® and stimulants like
Adderall®. In fact, the Monitoring the Future
survey of adolescent drug use and attitudes
shows that prescription and over-the-counter
medications account for a majority of the drugs
most commonly abused by high-school seniors.
36.4
Why do adolescents
take drugs?
Percent of High School Seniors Using in the Past Year
1.
0
A
The top drug used in this category is Adderall (7.4%)
*The top drugs used in this category are Vicodin (5.3%) and OxyContin (3.6%)
Source: Monitoring the Future National Results on Adolescent
Drug Use: Summary of Key Findings, 2013.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 13
3.
How do adolescents
become addicted to
drugs, and which factors
increase risk?
Addiction occurs when repeated use of drugs
changes how a person’s brain functions over
time. The transition from voluntary to compulsive
drug use reflects changes in the brain’s natural
inhibition and reward centers that keep a
person from exerting control over the impulse
to use drugs even when there are negative
consequences—the defining characteristic of
addiction.
Some people are more vulnerable to this
process than others, due to a range of possible
risk factors. Stressful early life experiences such
as being abused or suffering other forms of
trauma are one important risk factor. Adolescents
with a history of physical and/or sexual abuse
are more likely to be diagnosed with substance
use disorders.30 Many other risk factors,
including genetic vulnerability, prenatal exposure
to alcohol or other drugs, lack of parental
supervision or monitoring, and association with
drug-using peers also play an important role.31
At the same time, a wide range of genetic and
environmental influences that promote strong
psychosocial development and resilience may
work to balance or counteract risk factors,
making it ultimately hard to predict which
individuals will develop substance use
disorders and which won’t.
4. Is it possible for teens
to become addicted to
marijuana?
Yes. Contrary to common belief, marijuana is
addictive. Estimates from research suggest that
about 9 percent of users become addicted to
marijuana; this number increases among those
who start young (to about 17 percent, or 1 in
6) and among daily users (to 25–50 percent).32
Thus, many of the nearly 7 percent of highschool seniors who (according to annual survey
data)33 report smoking marijuana daily or almost
daily are well on their way to addiction, if not
already addicted, and may be functioning at a
sub-optimal level in their schoolwork and in
other areas of their lives.
Long-term marijuana users who try to quit
report withdrawal symptoms including irritability,
sleeplessness, decreased appetite, anxiety, and
drug craving, all of which can make it difficult
to stay off the drug. Behavioral interventions,
including Cognitive-Behavioral Therapy and
Contingency Management (providing tangible
incentives to patients who remain drug-free)
have proven to be effective in treating marijuana
addiction (see Page 24 for descriptions of
these treatments). Although no medications
are currently available to treat marijuana
addiction, it is possible that medications to ease
marijuana withdrawal, block its intoxicating
effects, and prevent relapse may emerge from
recent discoveries about the workings of the
endocannabinoid system, a signaling system in
the body and brain that uses chemicals related
to the active ingredients in marijuana.
Legalization of marijuana for adult recreational
use and for medicinal purposes is currently
the subject of much public debate. Whatever
the outcome, public health experts are worried
about use increasing among adolescents,
since marijuana use as a teen may harm the
developing brain, lower IQ, and seriously impair
the ability to drive safely, especially when
combined with alcohol.
Parents seeking more information about the
effects of marijuana on teens are encouraged
to see information offered on NIDA’s Web
site: http://www.drugabuse.gov/drugs-abuse/
marijuana.
14 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
The Dangers of Inhalants
Various household products, including
cleaning fluids, glues, lighter fluid, aerosol
sprays, and office supplies like markers
and correction fluid, have fumes that are
sometimes breathed to obtain a brief,
typically alcohol-like high. Because of their
ready availability, these are frequently
among the earliest substances youth abuse;
they are generally less popular among older
teens, who have greater access to other
substances like alcohol or marijuana.
Although the high from inhalants typically
wears off quickly, immediate health
consequences of inhalant abuse may be
severe: In addition to nausea or vomiting,
users risk suffocation and heart failure—
called “sudden sniffing death.” Serious
long-term consequences include liver and
kidney damage, hearing loss, bone marrow
damage, and brain damage. Although
addiction to inhalants is not very common, it
can occur with repeated abuse.
Early abuse of inhalants may also be a
warning sign for later abuse of other drugs.
One study found that youth who used
inhalants before age 14 were twice as likely
to later use opiate drugs.34 So it is important
for parents to safeguard household products
and be alert to signs that their younger
teens may be abusing these substances.
5.
Is abuse of prescription
medications as
dangerous as other
forms of illegal drug use?
Psychoactive prescription drugs, which include
opioid pain relievers, stimulants prescribed for
ADHD, and central nervous system depressants
prescribed to treat anxiety or sleep disorders, are
all effective and safe when taken as prescribed
by a doctor for the conditions they are intended
to treat. However, they are frequently abused—
that is, taken in other ways, in other quantities,
or by people for whom they weren’t prescribed—
and this can have devastating consequences.
In the case of opioid pain relievers such
as Vicodin® or OxyContin®, there is a great
risk of addiction and death from overdose
associated with such abuse. Especially when
pills are crushed and injected or snorted, these
medications affect the brain and body very much
like heroin, including euphoric effects and a
hazardous suppression of breathing (the reason
for death in cases of fatal opioid overdose).
In fact, some young people who develop
prescription opioid addictions shift to heroin
because it may be cheaper to obtain.35
ADHD medications such as Adderall® (which
contains the stimulant amphetamine) are
increasingly popular among young people who
take them believing it will improve their school
performance. This too is a dangerous trend.
Prescription stimulants act in the brain similarly
to cocaine or illegal amphetamines, raising heart
rate and blood pressure, as well as producing
an addictive euphoria. Other than promoting
wakefulness, it is unclear that such medications
actually provide much or any cognitive benefit,
however, beyond the benefits they provide when
taken as prescribed to those with ADHD.36
6.
Are steroids addictive
and can steroid abuse be
treated?
Some adolescents—mostly male—abuse
anabolic-androgenic steroids in order to improve
their athletic performance and/or improve their
appearance by helping build muscles. Steroid
abuse may lead to serious, even irreversible,
health problems including kidney impairment,
liver damage, and cardiovascular problems that
raise the risk of stroke and heart attack (even
in young people). An undetermined percentage
of steroid abusers may also become addicted
to the drugs—that is, continuing to use them
despite physical problems and negative effects
on social relations—but the mechanisms
causing this addiction are more complex than
those for other drugs of abuse.
Steroids are not generally considered
intoxicating, but animal studies have shown that
chronic steroid use alters the same dopamine
reward pathways in the brain that are affected
by other substances. Other factors such as
underlying body image problems also contribute
to steroid abuse.37 Moreover, when people stop
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 15
using steroids, they can experience withdrawal
symptoms such as hormonal changes that
produce fatigue, loss of muscle mass and sex
drive, and other unpleasant physical changes.
One of the more dangerous withdrawal
symptoms is depression, which has led to
suicide in some people discontinuing steroids.
Steroid abuse is also frequently complicated
by abuse of other substances taken either as
part of a performance-enhancing regimen (such
as stimulants) or to help manage pain-, sleep-,
or mood-related side effects (such as opioids,
cannabis, and alcohol).38
Because of this complicated mix of issues,
treatment for steroid abuse necessarily involves
addressing all related mental and physical
health issues and substance use disorders
simultaneously. This may involve behavioral
treatments as well as medications to help
normalize the hormonal system and treat
any depression or pain issues that may be
present. If symptoms are severe or prolonged,
hospitalization may be needed.
7.
How do other mental
health conditions relate
to substance use in
adolescents?
Drug use in adolescents frequently overlaps with
other mental health problems. For example, a
teen with a substance use disorder is more likely
to have a mood, anxiety, learning, or behavioral
disorder too. Sometimes drugs can make
accurately diagnosing these other problems
complicated. Adolescents may begin taking
drugs to deal with depression or anxiety, for
example; on the other hand, frequent drug use
may also cause or precipitate those disorders.
Adolescents entering drug abuse treatment
should be given a comprehensive mental health
screening to determine if other disorders are
present. Effectively treating a substance use
disorder requires addressing drug abuse and
other mental health problems simultaneously.
Addiction occurs when repeated use
of drugs changes how a person’s
brain functions over time.
8.
Does treatment of
ADHD with stimulant
medications like Ritalin®
and Adderall® increase
risk of substance abuse
later in life?
Prescription stimulants are effective at treating
attention disorders in children and adolescents,
but concerns have been raised that they could
make a young person more vulnerable to
developing later substance use disorders. On
balance, the studies conducted so far have
found no differences in later substance use for
ADHD-affected children who received treatment
versus those that did not. This suggests that
treatment with ADHD medication does not affect
(either negatively or positively) an individual’s
risk for developing a substance use disorder.39
9.
What are signs of drug
use in adolescents,
and what role can
parents play in getting
treatment?
If an adolescent starts behaving differently for
no apparent reason––such as acting withdrawn,
frequently tired or depressed, or hostile–it could
be a sign he or she is developing a drug-related
problem. Parents and others may overlook such
signs, believing them to be a normal part of
puberty.
Other signs include:
• a change in peer group
• carelessness with grooming
• decline in academic performance
• missing classes or skipping school
• loss of interest in favorite activities
• changes in eating or sleeping habits
• deteriorating relationships with family
members and friends
Parents tend to underestimate the risks or
seriousness of drug use. The symptoms listed
here suggest a problem that may already have
become serious and should be evaluated to
determine the underlying cause—which could
be a substance abuse problem or another
16 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
11.
mental health or medical disorder. Parents who
are unsure whether their child is abusing drugs
can enlist the help of a primary care physician,
school guidance counselor, or drug abuse
treatment provider.
Parents seeking treatment for an adolescent
child are encouraged to see NIDA’s booklet,
Seeking Drug Abuse Treatment: Know What to
Ask (http://www.drugabuse.gov/publications/
seeking-drug-abuse-treatment) and see the
Treatment Referral Resources section of this
guide (page 31).
10.
How can parents
participate in their
adolescent child’s
treatment?
Parents can actively support their child and
engage with him or her during the treatment and
recovery process. Apart from providing moral
and emotional support, parents can also play a
crucial role in supporting the practical aspects
of treatment, such as scheduling and making
appointments, as well as providing needed
structure and supervision through household
rules and monitoring. Also, several evidencebased treatments for adolescents specifically
address drug abuse within the family context.
Family-based drug abuse treatment can help
improve communication, problem-solving,
and conflict resolution within the household.
Treatment professionals can help parents
and other family members identify ways they
can support the changes the adolescent
achieves through treatment (see “Family-Based
Approaches,” pages 25–26).
What role can medical
professionals play in
addressing substance
abuse (including abuse of
prescription drugs) among
adolescents?
Medical professionals have an important role to
play in screening their adolescent patients for
drug use, providing brief interventions, referring
them to substance abuse treatment if necessary,
and providing ongoing monitoring and follow-up.
Screening and brief interventions do not have to be
time-consuming and can be integrated into general
medical settings.
• Screening. Screening and brief assessment
tools administered during annual routine
medical checkups can detect drug use before
it becomes a serious problem. The purpose
of screening is to look for evidence of any use
of alcohol, tobacco, or illicit drugs or abuse of
prescription drugs and assess how severe the
problem is. Results from such screens can
indicate whether a more extensive assessment
and possible treatment are necessary (see
“Screening Tools and Brief Assessments Used
with Adolescents,” below).40 Screening as a
part of routine care also helps to reduce the
stigma associated with being identified as
having a drug problem.
Screening Tools and Brief
Assessments Used with
Adolescents
Screening tools are available and outlined
in the American Academy of Pediatrics
(AAP) publications, Tobacco, Alcohol, and
Other Drugs: The Role of the Pediatrician in
Prevention, Identification, and Management
of Substance Abuse41 and Substance Use
Screening, Brief Intervention and Referral to
Treatment for Pediatricians.42
In addition, the Alcohol Screening and Brief
Intervention for Youth: A Practitioner’s Guide
developed by the National Institute on Alcohol
Abuse and Alcoholism provides information
on identifying adolescents at high risk for
alcohol abuse.43
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 17
•
•
•
•
Brief Intervention. Adolescents who report
using drugs can be given a brief intervention
to reduce their drug use and other risky
behaviors. Specifically, they should be
advised how continued drug use may harm
their brains, general health, and other areas
of their life, including family relationships
and education. Adolescents reporting no
substance use can be praised for staying
away from drugs and rescreened during their
next physical.
Referral. Adolescents with substance
use disorders or those that appear to be
developing a substance use disorder may
need a referral to substance abuse treatment
for more extensive assessment and care.
Follow-up. For patients in treatment, medical
professionals can offer ongoing support of
treatment participation and abstinence from
drugs during follow-up visits. Adolescent
patients who relapse or show signs of
continuing to use drugs may need to be
referred back to treatment.
Before prescribing medications that can
potentially be abused, clinicians can assess
patients for risk factors such as mental illness
or a family history of substance abuse,
consider an alternative medication with less
abuse potential, more closely monitor patients
at high risk, reduce the length of time between
visits for refills so fewer pills are on hand,
and educate both patients and their parents
about appropriate use and potential risks
of prescription medications, including the
dangers of sharing them with others.
12.
Is adolescent tobacco use
treated similarly to other
drug use?
Yes. People often don’t think of tobacco use as a
kind of “drug abuse” that requires treatment, and
motives for quitting smoking may be somewhat
different than motives for quitting other drugs.
But tobacco use has well-known health risks––
especially when begun in the teen years––and
the highly addictive nicotine in tobacco can make
treatment a necessity to help an adolescent quit.
Laboratory research also suggests that nicotine
may increase the rewarding and addictive effects
of other drugs, making it a potential contributor to
other substance use disorders.
Common treatment approaches like CognitiveBehavioral Therapy are now being used
to help adolescents quit smoking (and quit
using other drugs) by helping them “train their
brains” so they learn to recognize and control
their cravings and better deal with life stress.
Other therapies like Contingency Management
and Motivational Enhancement use incentives
and motivation techniques to help teens
reduce or stop smoking.44 (See page 24 for
descriptions of these treatments.)
Tobacco use often accompanies other drug
use and needs to be addressed as part of
other substance use disorder treatment. In
a recent survey, nearly 55 percent of current
adolescent cigarette smokers (ages 12 to 17)
were also illicit drug users (by comparison,
only about 6 percent of those who did
not smoke used any illicit drugs).45 Also,
cigarette smoking can be an indicator of other
psychiatric disorders, which can be identified
through comprehensive screening
by a treatment provider.
13.
Are there medications
to treat adolescent
substance abuse?
Several medications are approved by the
FDA to treat addiction to opioids, alcohol, and
nicotine in individuals 18 and older. In most
cases, little research has been conducted
to evaluate the safety and efficacy of these
medications for adolescents; however,
some health care providers do use these
medications “off-label,” especially in older
adolescents (see “Addiction Medications,”
pages 26–28).
14.
Do girls and boys have
different treatment
needs?
Adolescent girls and boys may have different
developmental and social issues that may
call for different treatment strategies or
emphases. For example, girls with substance
use disorders may be more likely to also have
mood disorders such as depression or to have
experienced physical or sexual abuse. Boys
with substance use disorders are more likely
18 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
to also have conduct, behavioral, and learning
problems, which may be very disruptive to their
school, family, or community. Treatments should
take into account the higher rate of internalizing
and traumatic stress disorders among adolescent
girls, the higher rate of externalizing disruptive
disorders and juvenile justice problems among
adolescent boys, and other gender differences
that may play into adolescent substance use
disorders.
15.
What are the unique
treatment needs of
adolescents from
different racial/ethnic
backgrounds?
Treatment providers are urged to consider the
unique social and environmental characteristics
that may influence drug abuse and treatment
for racial/ethnic minority adolescents, such as
stigma, discrimination, and sparse community
resources. With the growing number of immigrant
children living in the United States, issues of
culture of origin, language, and acculturation
are important considerations for treatment. The
demand for bilingual treatment providers to work
with adolescents and their families will also be
increasing as the diversity of the U.S. population
increases.
16.
What role can the
juvenile justice system
play in addressing
adolescent drug abuse?
Involvement in the juvenile justice system is
unfortunately a reality for many substanceabusing adolescents, but it presents a valuable
opportunity for intervention. Substance use
treatment can be incorporated into the juvenile
justice system in several ways. These include:
• screening and assessment for drug abuse
upon arrest
• initiation of treatment while awaiting trial
• access to treatment programs in the community
in lieu of incarceration (e.g., juvenile treatment
drug courts)46,47
• treatment during incarceration followed by
community-based treatment after release
Coordination and collaboration between juvenile
justice professionals, drug abuse treatment
providers, and other social service agencies
are essential in getting needed treatment to
adolescent offenders, about one half of whom
have substance use disorders.48
17.
What role do 12-step
groups or other recovery
support services play in
addiction treatment for
adolescents?
Adolescents may benefit from participation
in self- or mutual-help groups like 12-step
programs or other recovery support services,
which can reinforce abstinence from drug use
and other changes made during treatment, as
well as support progress made toward important
goals like succeeding in school and reuniting
with family. Peer recovery support services and
recovery high schools provide a community
setting where fellow recovering adolescents can
share their experiences and support each other
in living a drug-free life.
It is important to note that recovery support
services are not a substitute for drug abuse
treatment. Also, there is sometimes a risk in
support-group settings that conversation among
adolescents can turn to talk extolling drug use;
group leaders need to be aware of such a
possibility and be ready to direct the discussion
in more positive directions if necessary.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 19
IV. TREATMENT SETTINGS
20 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
T
reatment for substance use disorders
is delivered at varying levels of care
in many different settings. Because
no single treatment is appropriate
for every adolescent, treatments
must be tailored for the individual. Based on
the consensus of drug treatment experts, the
American Society of Addiction Medicine (ASAM)
has developed guidelines for determining the
appropriate intensity and length of treatment for
adolescents with substance abuse problems,
based on an assessment involving six areas:49
(1) Level of intoxication and potential for
withdrawal
(2) Presence of other medical conditions
(3) Presence of other emotional, behavioral, or
cognitive conditions
(4) Readiness or motivation to change
(5) Risk of relapse or continued drug use
(6) Recovery environment (e.g., family, peers,
school, legal system)
With a substance use disorder—as with any
other medical condition—treatment must
be long enough and strong enough to be
effective. Just as an antibiotic must be taken for
sufficient time to kill a bacterial infection, even
though symptoms may already have subsided,
substance abuse treatment must continue for
a sufficient length of time to treat the disease.
Undertreating a substance use disorder—
providing lower than the recommended level
of care or a shorter length of treatment than
recommended—will increase the risk of relapse
and could cause the patient, his or her family
members, or the referring juvenile justice system
to lose hope in the treatment because they will
see it as ineffective.
This section will review the settings in which
adolescent drug abuse treatment most often
occurs.
Outpatient/Intensive Outpatient
Adolescent drug abuse treatment is most
commonly offered in outpatient settings. When
delivered by well-trained clinicians, this can
be highly effective. Outpatient treatment is
traditionally recommended for adolescents
with less severe addictions, few additional
mental health problems, and a supportive living
environment, although evidence suggests that
more severe cases can be treated in outpatient
settings as well. Outpatient treatment varies in
the type and intensity of services offered and
may be delivered on an individual basis or in
a group format (although research suggests
group therapy can carry certain risks; see
“Group Therapy for Adolescents,” page 23).
Low- or moderate-intensity outpatient care
is generally delivered once or twice a week.
Intensive outpatient services are delivered more
frequently, typically more than twice a week for
at least 3 hours per day. Outpatient programs
may offer drug abuse prevention programming
(focused on deterring further drug use) or other
behavioral and family interventions.50,51
Partial Hospitalization
Adolescents with more severe substance use
disorders but who can still be safely managed
in their home living environment may be
referred to a higher level of care called partial
hospitalization or “day treatment.” This setting
offers adolescents the opportunity to participate
in treatment 4–6 hours a day at least 5 days a
week while living at home.52
Residential/Inpatient Treatment
Residential treatment is a resource-intense high
level of care, generally for adolescents with
severe levels of addiction whose mental health
and medical needs and addictive behaviors
require a 24-hour structured environment to
make recovery possible. These adolescents
may have complex psychiatric or medical
problems or family issues that interfere with
their ability to avoid substance use. One wellknown long-term residential treatment model
is the therapeutic community (TC). TCs use
a combination of techniques to “resocialize”
the adolescent and enlist all the members of
the community, including residents and staff,
as active participants in treatment. Treatment
focuses on building personal and social
responsibility and developing new coping skills.
Such programs offer a range of family services
and may require family participation if the TC is
sufficiently close to where the family lives. Shortterm residential programs also exist.53
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 21
V.EVIDENCE-BASED
APPROACHES TO
TREATING ADOLESCENT
SUBSTANCE USE
DISORDERS
22 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
R
esearch evidence supports the
effectiveness of various substance
abuse treatment approaches for
adolescents. Examples of specific
evidence-based approaches
are described below, including behavioral
and family-based interventions as well as
medications. Each approach is designed
to address specific aspects of adolescent
drug use and its consequences for the
individual, family, and society. In order for
any intervention to be effective, the clinician
providing it needs to be trained and wellsupervised to ensure that he or she adheres
to the instructions and guidance described in
treatment manuals. Most of these treatments
have been tested over short periods of
12–16 weeks, but for some adolescents,
longer treatments may be warranted; such a
decision is made on a case-by-case basis.
The provider should use clinical judgment
to select the evidence-based approach that
seems best suited to the patient and his or
her family.*
BEHAVIORAL APPROACHES
Behavioral interventions help adolescents
to actively participate in their recovery from
drug abuse and addiction and enhance their
ability to resist drug use. In such approaches,
therapists may provide incentives to remain
abstinent, modify attitudes and behaviors
related to drug abuse, assist families in
improving their communication and overall
interactions, and increase life skills to
handle stressful circumstances and deal
with environmental cues that may trigger
intense craving for drugs. Below are some
behavioral treatments shown to be effective in
addressing substance abuse in adolescents
(listed in alphabetical order).
*
Group Therapy for Adolescents
Adolescents can participate in group
therapy and other peer support programs
during and following treatment to help them
achieve abstinence. When led by welltrained clinicians following well-validated
Cognitive-Behavioral Therapy (CBT)
protocols (see page 24), groups can provide
positive social reinforcement through peer
discussion and help enforce incentives
to staying off drugs and living a drug-free
lifestyle.
However, group treatment for adolescents
carries a risk of unintended adverse effects:
Group members may steer conversation
toward talk that glorifies or extols drug
use, thereby undermining recovery goals.
Trained counselors need to be aware of that
possibility and direct group activities and
discussions in a positive direction.
Adolescent Community
Reinforcement Approach (A-CRA)
A-CRA is an intervention that seeks to help
adolescents achieve and maintain abstinence
from drugs by replacing influences in their
lives that had reinforced substance use with
healthier family, social, and educational or
vocational reinforcers. After assessing the
adolescent’s needs and levels of functioning,
the therapist chooses from among 17 A-CRA
procedures to address problem-solving, coping,
and communication skills and to encourage
active participation in constructive social and
recreational activities.54
The treatments listed in this book are not intended to be a comprehensive list of efficacious evidence-based treatment approaches for adolescents.
NIDA continues supporting research developing new approaches to address adolescent drug abuse.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 23
Cognitive-Behavioral Therapy (CBT)
CBT strategies are based on the theory that
learning processes play a critical role in the
development of problem behaviors like drug
abuse. A core element of CBT is teaching
participants how to anticipate problems and
helping them develop effective coping strategies.
In CBT, adolescents explore the positive and
negative consequences of using drugs. They
learn to monitor their feelings and thoughts and
recognize distorted thinking patterns and cues
that trigger their substance abuse; identify and
anticipate high-risk situations; and apply an
array of self-control skills, including emotional
regulation and anger management, practical
problem solving, and substance refusal. CBT
may be offered in outpatient settings in either
individual or group sessions (see “Group
Therapy for Adolescents,” page 23) or in
residential settings.55
Contingency Management (CM)
Research has demonstrated the effectiveness
of treatment using immediate and tangible
reinforcements for positive behaviors to modify
problem behaviors like substance abuse. This
approach, known as Contingency Management
(CM), provides adolescents an opportunity
to earn low-cost incentives such as prizes or
cash vouchers (for food items, movie passes,
and other personal goods) in exchange for
participating in drug treatment, achieving
important goals of treatment, and not using
drugs. The goal of CM is to weaken the influence
of reinforcement derived from using drugs and
to substitute it with reinforcement derived from
healthier activities and drug abstinence. For
adolescents, CM has been offered in a variety
of settings, and parents can be trained to apply
this method at home. CM is typically combined
either with a psychosocial treatment or a
medication (where available). Recent evidence
also supports the use of Web-based CM to help
adolescents stop smoking.56
Motivational Enhancement Therapy
(MET)
MET is a counseling approach that helps
adolescents resolve their ambivalence about
engaging in treatment and quitting their drug
use. This approach, which is based on a
technique called motivational interviewing,
typically includes an initial assessment of
the adolescent’s motivation to participate in
treatment, followed by one to three individual
sessions in which a therapist helps the patient
develop a desire to participate in treatment by
providing non-confrontational feedback. Being
empathic yet directive, the therapist discusses
the need for treatment and tries to elicit selfmotivational statements from the adolescent
to strengthen his or her motivation and build
a plan for change. If the adolescent resists,
the therapist responds neutrally rather than by
contradicting or correcting the patient. MET,
while better than no treatment, is typically not
used as a stand-alone treatment for adolescents
with substance use disorders but is used to
motivate them to participate in other types of
treatment.57
Twelve-Step Facilitation Therapy
Twelve-Step Facilitation Therapy is designed to
increase the likelihood that an adolescent with
a drug abuse problem will become affiliated
and actively involved in a 12-step program
like Alcoholics Anonymous (AA) or Narcotics
Anonymous (NA). Such programs stress the
participant’s acceptance that life has become
unmanageable, that abstinence from drug use
is needed, and that willpower alone cannot
overcome the problem. The benefits of 12step participation for adults in extending the
benefits of addiction treatment appear to apply
to adolescent outpatients as well, according
to recent research. Research also suggests
adolescent-specific 12-step facilitation strategies
may help enhance outpatient attendance rates.58
Behavioral interventions help adolescents to actively participate in their
recovery from drug abuse and addiction and enhance their ability to resist
drug use.
24 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
FAMILY-BASED APPROACHES
Family-based approaches to treating
adolescent substance abuse highlight
the need to engage the family, including
parents, siblings, and sometimes peers,
in the adolescent’s treatment. Involving
the family can be particularly important,
as the adolescent will often be living with
at least one parent and be subject to the
parent’s controls, rules, and/or supports.
Family-based approaches generally address
a wide array of problems in addition to the
young person’s substance problems, including
family communication and conflict; other cooccurring behavioral, mental health, and
learning disorders; problems with school or
work attendance; and peer networks. Research
shows that family-based treatments are highly
efficacious; some studies even suggest they are
superior to other individual and group treatment
approaches.59 Typically offered in outpatient
settings, family treatments have also been tested
successfully in higher-intensity settings such as
residential and intensive outpatient programs.
Below are specific types of family-based
treatments shown to be effective in treating
adolescent substance abuse.
interaction patterns. BSFT can be adapted to
a broad range of family situations in various
settings (mental health clinics, drug abuse
treatment programs, social service settings,
families’ homes) and treatment modalities (as a
primary outpatient intervention, in combination
with residential or day treatment, or as an
aftercare/continuing-care service following
residential treatment).60
Brief Strategic Family Therapy (BSFT)
Family Behavior Therapy (FBT)
BSFT is based on a family systems approach
to treatment, in which one member’s problem
behaviors are seen to stem from unhealthy
family interactions. Over the course of 12–16
sessions, the BSFT counselor establishes a
relationship with each family member, observes
how the members behave with one another,
and assists the family in changing negative
FBT, which has demonstrated positive results
in both adults and adolescents, combines
behavioral contracting with contingency
management to address not only substance
abuse but other behavioral problems as
well. The adolescent and at least one parent
participate in treatment planning and choose
specific interventions from a menu of evidencebased treatment options. Therapists encourage
family members to use behavioral strategies
taught in sessions and apply their new skills
to improve the home environment. They set
behavioral goals for preventing substance
use and reducing risk behaviors for sexually
transmitted diseases like HIV, which are
reinforced through a contingency management
(CM) system (see description on page 24).
Goals are reviewed and rewards provided at
each session.61
Involving the family can be
particularly important in
adolescent substance abuse
treatment.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 25
Multidimensional Family Therapy
(MDFT)
MDFT is a comprehensive family- and
community-based treatment for substanceabusing adolescents and those at high risk for
behavior problems such as conduct disorder
and delinquency. The aim is to foster family
competency and collaboration with other
systems like school or juvenile justice. Sessions
may take place in a variety of locations,
including in the home, at a clinic, at school, at
family court, or in other community locations.
MDFT has been shown to be effective even with
more severe substance use disorders and can
facilitate the reintegration of substance abusing
juvenile detainees into the community.63
Multisystemic Therapy (MST)
Functional Family Therapy (FFT)
FFT combines a family systems view of family
functioning (which asserts that unhealthy
family interactions underlie problem behaviors)
with behavioral techniques to improve
communication, problem-solving, conflict
resolution, and parenting skills. Principal
treatment strategies include (1) engaging
families in the treatment process and enhancing
their motivation for change and (2) modifying
family members’ behavior using CM techniques,
communication and problem solving, behavioral
contracts, and other methods.62
Undertreating a substance use
disorder will increase the risk of
relapse.
MST is a comprehensive and intensive familyand community-based treatment that has been
shown to be effective even with adolescents
whose substance abuse problems are severe
and with those who engage in delinquent and/
or violent behavior. In MST, the adolescent’s
substance abuse is viewed in terms of
characteristics of the adolescent (e.g., favorable
attitudes toward drug use) and those of his or
her family (e.g., poor discipline, conflict, parental
drug abuse), peers (e.g., positive attitudes
toward drug use), school (e.g., dropout, poor
performance), and neighborhood (e.g., criminal
subculture). The therapist may work with the
family as a whole but will also conduct sessions
with just the caregivers or the adolescent
alone.64
ADDICTION MEDICATIONS
Several medications have been found to
be effective in treating addiction to opioids,
alcohol, or nicotine in adults, although none of
these medications have been approved by the
FDA to treat adolescents. In most cases, only
preliminary evidence exists for the effectiveness
and safety of these medications in people
under 18, and there is no evidence on the
neurobiological impact of these medications
26 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
on the developing brain. However, despite
the relative lack of evidence, some health
care providers do use medications “off-label”
when treating adolescents (especially older
adolescents) who are addicted to opioids,
nicotine, or (less commonly) alcohol. Newer
compounds continue to be studied for possibly
treating substance use disorders in adults and
adolescents, but none other than those listed
here have shown conclusive results.
Note that there are currently no FDA-approved
medications to treat addiction to cannabis,
cocaine, or methamphetamine in any age
group.
Opioid Use Disorders
Buprenorphine reduces or eliminates opioid
withdrawal symptoms, including drug cravings,
without producing the “high” or dangerous side
effects of heroin and other opioids. It does this
by both activating and blocking opioid receptors
in the brain (i.e., it is what is known as a partial
opioid agonist). It is available for sublingual
(under-the-tongue) administration both in a
stand-alone formulation (called Subutex®)
and in combination with another agent called
naloxone. The naloxone in the combined
formulation (marketed as Suboxone®) is
included to deter diversion or abuse of the
medication by causing a withdrawal reaction
if it is intravenously injected.65 Physicians with
special certification may provide office-based
buprenorphine treatment for detoxification
and/or maintenance therapy.66 It is sometimes
prescribed to older adolescents on the basis
of two research studies indicating its efficacy
for this population,67,68 even though it is not
approved by the FDA for pediatric use.*
Methadone also prevents withdrawal
symptoms and reduces craving in opioidaddicted individuals by activating opioid
receptors in the brain (i.e., a full opioid agonist).
*
Adolescent drug abuse treatment is
most commonly offered in outpatient
settings.
It has a long history of use in treatment of
opioid dependence in adults, and is available
in specially licensed methadone treatment
programs. In select cases and in some States,
opioid-dependent adolescents between the ages
of 16 and 18 may be eligible for methadone
treatment, provided they have two documented
failed treatments of opioid detoxification or
drug-free treatment and have a written consent
for methadone signed by a parent or legal
guardian.69
Naltrexone is approved for the prevention of
relapse in adult patients following complete
detoxification from opioids. It acts by blocking
the brain’s opioid receptors (i.e., an opioid
antagonist), preventing opioid drugs from acting
on them and thus blocking the high the user
would normally feel and/or causing withdrawal if
recent opioid use has occurred. It can be taken
orally in tablets or as a once-monthly injection
given in a doctor’s office (a preparation called
Vivitrol®).70
Alcohol Use Disorders‡
Acamprosate (Campral®) reduces withdrawal
symptoms by normalizing brain systems
disrupted by chronic alcohol consumption in
adults.
Disulfiram (Antabuse®) inhibits an enzyme
involved in the metabolism of alcohol, causing an
unpleasant reaction if alcohol is consumed after
taking the medication.71
According to the FDA label, “SUBOXONE and SUBUTEX are not recommended for use in pediatric patients. The safety and effectiveness of
SUBOXONE and SUBUTEX in patients below the age of 16 have not been established.”
‡ Medication-assisted therapies are rarely used to treat adolescent alcohol use disorders.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 27
Naltrexone decreases alcohol-induced euphoria
and is available in both oral tablets and longacting injectable preparations (as in its use for
the treatment of opioid addiction, above).
Nicotine Use Disorders
Bupropion, commonly prescribed for
depression, also reduces nicotine cravings and
withdrawal symptoms in adult smokers.72
Nicotine Replacement Therapies (NRTs)
help smokers wean off cigarettes by activating
nicotine receptors in the brain. They are
available in the form of a patch, gum, lozenge,
nasal spray, or inhaler.73
Varenicline reduces nicotine cravings and
withdrawal in adult smokers by mildly stimulating
nicotine receptors in the brain.74
RECOVERY SUPPORT SERVICES
To reinforce gains made in treatment and to
improve their quality of life more generally,
recovering adolescents may benefit from
recovery support services, which include
continuing care, mutual help groups (such
as 12-step programs), peer recovery support
services, and recovery high schools. Such
programs provide a community setting where
fellow recovering persons can share their
experiences, provide mutual support to each
other’s struggles with drug or alcohol problems,
and in other ways support a substance-free
lifestyle. Note that recovery support services are
not substitutes for treatment. Also, the existing
research evidence for these approaches (with
the exception of Assertive Continuing Care) is
preliminary; anecdotal evidence supports the
effectiveness of peer recovery support services
and recovery high schools, for example, but
their efficacy has not been established through
controlled trials.
Assertive Continuing Care (ACC)
ACC is a home-based continuing-care
approach delivered by trained clinicians to
prevent relapse, and is typically used after
an adolescent completes therapy utilizing
the Adolescent Community Reinforcement
Approach (A-CRA, see page 23). Using positive
and negative reinforcement to shape behaviors,
along with training in problem-solving and
28 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
communication skills, ACC combines A-CRA
and assertive case management services
(e.g., use of a multidisciplinary team of
professionals, round-the-clock coverage,
assertive outreach) to help adolescents and
their caregivers acquire the skills to engage in
positive social activities.75
Mutual Help Groups
Mutual help groups such as the 12-step
programs Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA) provide ongoing
support for people with addictions to alcohol
or drugs, respectively, free of charge and in
a community setting. Participants meet in a
group with others in recovery, once a week or
more, sharing their experiences and offering
mutual encouragement. Twelve-step groups
are guided by a set of fundamental principles
that participants are encouraged to
adopt––including acknowledging that willpower
alone cannot achieve sustained sobriety,
that surrender to the group conscience must
replace self-centeredness, and that longterm recovery involves a process of spiritual
renewal.76
Peer Recovery Support Services
Peer recovery support services, such as
recovery community centers, help individuals
remain engaged in treatment and/or the
recovery process by linking them together
both in groups and in one-on-one relationships
with peer leaders who have direct experience
with addiction and recovery. Depending on
the needs of the adolescent, peer leaders
may provide mentorship and coaching and
help connect individuals to treatment, 12step groups, or other resources. Peer leaders
may also facilitate or lead community-building
activities, helping recovering adolescents build
alternative social networks and have drug- and
alcohol-free social options.77
Recovery High Schools
Recovery high schools are schools specifically
designed for students recovering from
substance abuse issues. They are typically part
of another school or set of alternative school
programs within the public school system,
but recovery school students are generally
separated from other students by means
of scheduling and physical barriers. Such
programs allow adolescents newly in recovery
to be surrounded by a peer group supportive of
recovery efforts and attitudes. Recovery schools
can serve as an adjunct to formal substance
abuse treatment, with students often referred by
treatment providers and enrolled in concurrent
treatment for other mental health problems.78
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 29
30 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
TREATMENT
REFERRAL
RESOURCES
Substance Abuse and Mental Health Services Administration
(SAMHSA) Treatment Locator: 1-800-662-HELP or search
www.findtreatment.samhsa.gov
The “Find A Physician” feature on the American Society
of Addiction Medicine (ASAM) Web site:
http://community.asam.org/search/default.asp?m=basic
The Patient Referral Program on the American Academy
of Addiction Psychiatry Web site:
http://www.aaap.org/patient-referral-program
The Child and Adolescent Psychiatrist Finder on the American
Academy of Child and Adolescent Psychiatry Web site:
http://www.aacap.org/cs/root/child_and_adolescent_
psychiatrist_finder/child_and_adolescent_psychiatrist_finder
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 31
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Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 35
NIH Publication Number 14-7953
January 2014
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